Low threshold services

The term “low-threshold” is used to describe a setting which aims to facilitate access by people who use drugs to social and health services, that typically includes outreach teams, street units, needle-exchange points, drop-in or contact centers, night shelters, substitution treatment programs, etc. To lower the threshold of access, such agencies choose specific locations and opening hours, require little bureaucracy, often no payment, no need to have official documents and are not linked to an obligation of the client to be or to become drug-free. They target people who are currently using drugs, “hard-to-reach” groups, high-risk groups among drug users and experimental users. Therefore, implementation of HIV/HCV testing in a low threshold centre could represent an important strategy to increase the uptake of HIV/HCV testing for those populations with poorer access to traditional health care.

The implementation of testing programs in low-threshold services requires the involvement of different professionals, each of them with a specific role: outreach/social workers for approaching, informing and motivating the target group to be tested; psychologists/counsellors/social workers for providing pre- and post-counselling; doctors/nurses for administering the rapid test. This definition of roles is important for ensuring the good quality of the provided services and facilitating collaboration and teamwork. Volunteers can be also involved in these kinds of programs, but it is fundamental that they receive specific training on drug use and related infectious diseases, in order to get a comprehensive knowledge of the topic and have a better work performance.

In these settings particularly important are approaching and recruitment of clients, in order to make their work more effective and valuable. It is always recommended to be flexible and ready to adapt the work to particular needs, situations and circumstances, so that the pre- and post-counselling will not be left out or minimized. In fact, it is not always easy to follow the indicated procedure step-by-step, due to the specific characteristics of the clients of this kind of services. For example, the distribution of informative leaflets should be accompanied or replaced by the verbal explanation of the aim and procedures of testing, because a high percentage of clients approached rarely read the leaflets; for clients who are in a hurry and don’t want to waste much time, it might be necessary to speed up the procedure.

RECRUITMENT OF CLIENTS/TARGET GROUPS FOR TESTING

It is important to widely disseminate information about testing possibilities in the low-threshold services through announcement or the distribution of informative leaflets among the clients in order to reach a wide spectrum of services users.

During the approaching and recruitment phase, the role of social workers and peers is fundamental. They represent the link between the target group and the health-care services because they can more effectively motivate people who use drugs to get tested (explaining the benefits and advantages of such service) and other safer behaviours, given that their relation with clients is based on trust and confidence. Staff members can use techniques typical of “motivational interviewing”, combining elements of empathy and negotiation with the aim to improve the client’s motivation toward his/her own health status.

The model of approaching must be clearly defined. Example: If someone says ‘I have been tested already, and I was negative’, this is not sufficient to exclude the person from the program. Check when the person was tested for the last time and if he/she has risk behaviours since that time.

On the other hand, for the clients willing to get tested, a second important selection step is required: to check their eligibility for testing according to the specific characteristics of the target group and the basic requirements for valid HIV and HCV testing. In order to check eligibility, the recruited clients should be asked the following “supplementary” questions:

• Have you been tested for HIV or HCV before? If yes, when?
• Have you been using drugs (heroin, cocaine, methamphetamine, amphetamines, opioid analgesics, buprenorphine) regularly in the past 3/6 months both injecting and not injecting?
• Are you willing to answer a questionnaire for risk assessment/data collection, and do you consent to the follow-up or possible visits to a clinic?
• Do you clearly understand the purposes and procedures of testing?

If somebody is unable to understand the objectives of the intervention and to give the informed consent, he/she must be considered not eligible for the testing! Moreover, it’s necessary to bear in mind the specific characteristics of the target group attending low-threshold services, particularly PWUD. Motivating these clients toward testing can be very hard, because they have other priorities and needs: they are in a hurry and don’t have enough time for getting tested; they are afraid of getting tested because they have engaged in risk behaviors; they want to avoid presence on the street because of fear of police. To cope with these problems, a solution can be the use of rewards and incentives such as phone cards, food or food tickets. Often, even the simple empathy, provision of a cup of coffee/ tea and some biscuits helped to approach people and motivate them to dedicate some time to their own health.

CRITERIA FOR SELECTION OF LOCATIONS FOR TESTING

The collaboration with other local services and facilities is useful for enlarging the number of potential beneficiaries and facilitating access to testing by high-risk groups of drug users such as homeless people. It is highly recommended to select places where the testing has never been offered, or is not provided on a regular basis, in order to reach people who most probably have never been tested or may prefer to get tested in non-medical settings. In addition, cooperation with other local low-threshold services can bring benefits in the long-term also, promoting the set-up of networks and referral systems which facilitate the access by people who use drugs to the required care, support and treatment programs.

Of course these networks are highly effective and fruitful if the cooperation among local actors is well-functioning and supported by a joint willingness to cooperate. This is not always easy to reach, in particular when talking about cooperation with public health services, which may have different opinions and methods of working with PWUD.